Health/Medical Questionnaire

If there is any question or statement on this form that you do not understand, ask for assistance by calling Cindy Smith, Director of Operations: 770-458-8500 ext. 704.

Thank you for completing the caregiver career application at Health Force of Georgia. There are three sections to the Health/Medical Questionnaire form. Be sure to complete ALL sections before clicking submit. The form will prompt you if there is required information missing in any section. Fields marked with a red * are required.

Employee Name*

FirstMiddleLast

The Georgia Subsequent Injury Trust Fund protects employers from excess liability for worker’s compensation when an injury to a worker merges with a preexisting impairment to cause a greater liability than would have resulted from the subsequent injury alone. In order to qualify for this protection, we must have prior knowledge of any preexisting illness or other ailment/injury you may have sustained in the past that may contribute to a percentage of permanent impairment. The presence of one or more impairments does not automatically render you unfit as an employee. All decisions will be made on job-related criteria. Reasonable accommodation will be made if appropriate, provided it does not pose an undue hardship.

1. Health Questions: Have You Ever Had...

Asthma?*

Yes

No

Migraine Headaches?*

Yes

No

Head Injury?*

Yes

No

Heart Trouble?*

Yes

No

Fainting Spells or Dizziness?*

Yes

No

Swelling in Ankles or Legs?*

Yes

No

Skin Rash or Eczema?*

Yes

No

Joint Pain or Arthritis?*

Yes

No

Epilepsy, Convulsions or Seizures?*

Yes

No

Cancer?*

Yes

No

Stomach Problems or Ulcers?*

Yes

No

Hepatitis?*

Yes

No

Thyroid Problems?*

Yes

No

Bladder Problems?*

Yes

No

Any serious wrist problem or Carpal Tunnel Syndrome?*

Yes

No

Surgery For Carpal Tunnel Syndrome?*

Yes

No

Surgery When?*

Which Hand?*

Left

Right

Work related illness or injury?*

Yes

No

When?*

What type?*

Varicose veins?*

Yes

No

Anemia or Sickle Cell Anemia?*

Yes

No

Tendonitis?*

Yes

No

Repetitive Motion Disorder?*

Yes

No

Stiffness of major weight bearing joints?*

Yes

No

Do you need glasses/contacts to read or for distance?*

Yes

No

Hay Fever?*

Yes

No

Diabetes?*

Yes

No

Color Blindness?*

Yes

No

Cerebral Palsy?*

Yes

No

Multiple Sclerosis*

Yes

No

Gallbladder Problems?*

Yes

No

Rheumatic Fever?*

Yes

No

Any Broken Bones?*

Yes

No

Which bone?*

Date Broken?

Had any type of surgery?*

Yes

No

Surgery When?*

What type of surgery?*

Reaction to any drugs?*

Yes

No

Which drugs?*

Cardiovascular Disorder?*

Yes

No

Tuberculosis?*

Yes

No

Hemophilia or bleeding disorder?*

Yes

No

Chronic infection of bone?*

Yes

No

Muscular Dystrophy?*

Yes

No

Ruptured disc?*

Yes

No

Wear a neck brace?*

Yes

No

Back injury?*

Yes

No

Back injury when?*

Had back surgery?*

Yes

No

Back surgery when?*

Difficulty or loss of hearing?*

Yes

No

Back trouble or pain?*

Yes

No

Hernia?*

Yes

No

High blood pressure?*

Yes

No

Take medication to control high blood pressure?*

Yes

No

Low blood pressure?*

Yes

No

Mental illness?*

Yes

No

Reaction to chemicals?*

Yes

No

Breathing problems or emphysema?*

Yes

No

Venereal Disease?*

Yes

No

END SECTION: Health Questions

2. Have You Ever Had....

Partial loss of uncorrected vision of more than 75 percent bilaterally?*

Yes

No

Psychoneurotic disability following confinement for treatment in a recognized medical or mental institution for a period greater than 6 months?*

Yes

No

Any permanent condition that constitutes 20 percent impairment of a foot, leg, hand or of the body as a whole?*

Yes

No

Do you or have you within the past year participated in recreational drug use?*

Yes

No

Have you ever participated in a drug abuse treatment program?*

Yes

No

Where?*

Do you currently take any prescription medication?*

Yes

No

If so, what?*

Do you have any condition or have you sustained any injury that would have an effect on your capacity to perform your job duties?*

Yes

No

Please explain*

Have you ever been hurt on the job or filed a worker’s compensation claim in the past?*

Yes

No

How many times?*

What years?*

Estimate the number of workdays you have lost in each of the past two years.*

Of these workdays lost, how many were due to illness or injuries?*

Please list the name of any doctors you have seen in the past two years. List your family doctor first.*

Type none if you have not seen or have a doctor.

Please provide any pertinent facts to every previous ailment or injury contributing to impairments, as well as all previous worker’s compensation claims.*

Type none if this does not apply to you.

End of Have You Ever Had....

3. For the job title of Healthcare Provider, you must be able to perform these functions or tasks:

9. Able to move intermittently throughout the workday, inclusive of sitting, standing, bending, pulling or moving objects and patients.*

Yes

No

Based on the information discussed and/or received, I feel that I*

Can perform the essential function of the job we’ve discussed.

Cannot perform the essential function of the job we’ve discussed.

If you cannot perform one or more of the job requirements noted above, and you feel we can modify any part of the job and/or schedule to enable you to do the work, please explain in the space provided. * Job modifications will be addressed on a case-by-case basis.

END SECTION For the job title of Healthcare Provider, you must be able to perform these functions or tasks:

If there is any question or statement on this form that you do not understand, ask for assistance by calling Cindy Smith, Director of Operations: 770-458-8500 ext. 704.

Our Worker’s Compensation Insurance Carrier checks for previous claims by name and social security number. If you have had a precious claim or injury, and fail to make us aware of it, you may legally be denied future benefits in the event of a new injury by operation of the landmark Rycroft ruling. For you own protection, please make us aware of any previous injuries.

I certify that the above answers are true to the best of my knowledge and understand that any false statements or omissions will make my subject to discharge.*